Nurses kept on after Rachel Johnston's death 'as they knew patients'

Rachel Johnston died in October 2018

Two nurses whose failures contributed to the death of a disabled woman carried on working at a care home because they "knew residents well".

Rachel Johnston died after an operation to remove all her teeth in 2018.

Staff at Pirton Grange, near Worcester, failed to spot her decline and did not carry out basic checks.

Worcestershire Coroner's Court heard that despite their actions amounting to misconduct, they were "consistent" and it was better if residents knew carers.

Senior coroner David Reid concluded last month that neglect contributed to her death. and the 49-year-old would probably have survived if the staff acted sooner.

Agency nurses Sheeba George and Gill Bennett failed to carry out routine checks and get emergency medical assistance, the inquest heard.

Giving her delayed evidence on Friday, care home manager Jane Colbourn said she accepted their actions amounted to misconduct, but they were allowed to carry on working at the home and other residents were not at risk.

"At the time I would say, although what's happened has happened, they were consistent nurses who knew those residents well and it's better to have those nurses rather than nurses that don't know the other 34 residents at all," she said.

If a similar incident happened now, then staff would have breached new policies introduced at the home since Miss Johnston's death and disciplinary procedures would have started and the staff no longer used, she said.

Regular audits on staff training were now conducted, existing rules had been "tightened" and there were longer handover times between staff, she said.

Rachel Johnston's mother Diana said she was relieved the nurses had now been reported to NMC

But she admitted she was not still familiar with the Nursing and Midwifery Council's (NMC's) misconduct rules, which she also did not know at the time of Miss Johnston's death.

The nurses were not referred to the NMC by care home owner Holmleigh Homes, until 23 February, Pasqueline Gill, the firm's quality assurance manager, told the hearing.

"I can't answer why they were kept employed and [the home] kept continuing using them," she said.

'Death not ignored'

Senior coroner David Reid concluded last month that neglect contributed to Miss Johnston's death.

She had all her teeth surgically extracted at Kidderminster Hospital on 26 October due to severe decay, but fell ill after returning to the care home.

By the time an ambulance was called two days later, her "entire brain had been starved of oxygen", her inquest heard, and she died two weeks later after her family decided to withdraw life support.

In conclusion Mr Reid said he was concerned about the late reporting of the nurses to the NMC and about disciplinary procedures.

"I am not satisfied sufficiently robust policies and procedures are in place which might ensure that, where there are sufficiently grave concerns about a nurse's conduct, that a disciplinary procedure is put in place," he said.

Mr Reid confirmed he would be ordering a report for the prevention of future deaths to be sent to Holmleigh Homes.

In a statement after the hearing, Miss Johnston's mother Diana said "justice had been done" through the coroner's investigation and she was relieved the nurses had now been reported.

"Nothing can bring Rachel back, but at least we can go forwards knowing her death has not been ignored," she said.